jecting from the side of the rectum, sometimes of a partition extending in a greater or less degree across it, and again of a transverse network of filaments. It may be seated in any part of the bowel, but is most commonly found about two or three inches above the anus. Instances have occurred in which the feces, accumulated above the stricture, have by their pressure produced ulceration, and thus made their way outward by a new passage. Such a passage

has been made around the stricture into the portion of the bowel beneath it, into the bladder, and into the vagina; the feces escaping in the first case per anum, in the second with the urine, and in the third from the vulva. In such instances, the relief obtained is usually but temporary; the patient being at length worn out by the continued irritation and discharge.

Anything may operate as a cause of this stricture, which is capable of producing chronic inflammation in the coats of the bowel. It is occasionally, perhaps, ascribable to venereal infection. Polypus of the rectum may produce the symptoms of stricture; but the affection is so purely surgical that I shall not treat of it here.

Stricture is in general amenable to treatment. The passages should be kept soft and unirritating by a proper attention to diet, and by the use of laxatives, especially those of a saline character. But the chief means of cure consists in the use of the bougie, which should be introduced daily, and gradually increased in size as the passage becomes enlarged. In some instances, the bistoury may be advantageously resorted to, especially when the stricture consists of a thin partition, and the symptoms of obstruction are threatening. In the circular stricture, which is usually seated about one-quarter or one-third of an inch above the anus, M. Robert prefers the use of the Vienna caustic (potassa with lime), which may be applied by means of a speculum. (See Am. Journ. of Med. Sci., N. S., xix. 512.) In cases where there is no alternative between death and the formation of an artificial anus, it is recommended by Amussat to make an opening into the colon, on the left side posteriorly, where it is not covered by the peritoneum; and the operation has been performed with success. (Dict. de Méd., xxvii. 303.)

2. Spasmodic Stricture of the Rectum.-In this form of stricture there is the same difficulty in evacuating the bowels, and the same lessened dimensions, and altered shape of the fecal cylinder; but these symptoms are not constant; and the feces will occasionally be found of the natural size. One of the characteristic signs is a feeling of constriction before or at the time of going to stool, and an occasional severe spasmodic pain, especially upon the application of an irritant. The introduction of a bougie will be resisted at one time, while at another, the instrument may pass with little or no difficulty. The stricture sometimes exists at the anal extremity of the rectum, depending on a spasmodic contraction of the internal or external sphincter, or both. It is then characterized by great difficulty in introducing the finger or an instrument through the anus, while, above the internal sphincter, the bowel may be quite relaxed. There is the same difficulty in passing the feces as in the other cases; and, after the evacuation, the patient experiences considerable pain for some time. From the great straining, the affection is apt to be attended with hemorrhoidal tumours. Spasmodic stricture is more apt to attack the young than the old, and is not commonly attended with that cachectic aspect, or general failure of health, which frequently marks the permanent organic affection.

This form of stricture may result from a peculiar irritability of the rectum; from disorder in the spinal marrow, or neighbouring pelvic viscera which may radiate irritation to this bowel; or from a morbid excitability of the nervous system in general, such as occurs in hysterical or hypochondriacal individuals.

The exciting cause may be anything capable of directly irritating the rectum, as hardened feces, vitiated bile, or acid in the bowels; or, in cases dependent upon the state of the general health, anything calculated to produce disorder in the nervous functions.

The indications in the treatment are, 1. to remove or prevent sources of direct irritation to the rectum; 2. to produce a relaxation of the spasm; 3. to diminish the morbid irritability of the bowel; 4. to remove any existing spinal disorder, and 5. to correct the morbid condition of the nervous system when this is in fault. To meet the first indication, the feces should be kept in a soft state by the use of a mild laxative diet, aided, if necessary, by the most unirritating laxative medicines, such as sulphur and the saline aperients; the biliary secretion, if deranged, should be corrected, and acid in the bowels neutralized; and all acrid or drastic cathartics, and especially aloes, should be carefully avoided. To produce relaxation of the spasm, recourse may be had to enemata of opium, belladonna, camphor, assafetida, and cold water, and to the use of the warm bath or semicupium. The bougie, frequently introduced, will sometimes be found useful by diminishing the irritability of the rectum; but, if this condition be connected with inflammation, leeches to the anus will be a more appropriate remedy. Spinal disorder should be encountered by leeches, and rubefacient, vesicatory, or pustulating applications. Finally, the morbid state of the nervous system is to be corrected by tonics, exercise, a regulated diet, proper mental occupation, and the occasional use of the nervous stimulants, as valerian and assafetida. In women, attention should be paid to the condition of the uterus, as disorder of this organ may operate injuriously upon the affection, not only by deranging the condition of the nervous system generally, but by transmitting a sympathetic irritation directly to the rectum; and the same remark is applicable to diseases of the genital organs in men, and of the urinary apparatus in both sexes.

Article VIII.

HEMORRHOIDS, or PILES.

This term has been applied both to hemorrhages from the rectum, and to certain tumours which form in and about the anus. In the former case, whether the hemorrhage is or is not accompanied with tumours, the affection is called bleeding piles; in the latter, when unconnected with any discharge, blind piles. The tumours are also distinguished into internal piles, which are within the sphincter ani, and external piles, which are without the sphineter. I shall pay little attention to these distinctions in the following remarks. Simple bleeding from the rectum, independent of tumours, though it may proceed from the same pathological condition as that which gives rise to the tumours, falls properly among the hemorrhages, and will be considered with them. I shall here speak of the hemorrhage only as an attendant or result of the tumours.

Two distinct ingredients often enter into the composition of the hemor rhoidal disease; 1. a peculiar constitutional disturbance which determines irritation and congestion of the rectum, and 2. tumours at the extremity of the bowel. The two may exist separately-the former occasionally running its course without resulting in tumours, the latter often originating in purely local causes; but they are very generally more or less associated. I distin guish the one by the name of the hemorrhoidal effort, the latter by that of hemorrhoidal tumours, or simply hemorrhoids.

The hemorrhoidal effort is frequently marked by certain symptoms of constitutional disorder, preceding or attending those of irritation or congestion of the rectum. Of the former are general uneasiness, mental dejection, or irritability, languor, uncomfortable sensations in the head, pain in the loins, dyspeptic feelings, constipation, and colicky pains; of the latter, a feeling of weight or tension in the region of the sacrum, heat about the anus, sometimes pains in these parts extending to the neighbouring pelvic viscera and to the lower extremities, a sensation of fulness in the lower portion of the rectum, and a disposition to go to stool, with little or no evacuation. This condition continues for three or four days, and then subsides spontaneously, or under treatment, to return under various excitements, and sometimes periodically, without any known cause, at intervals of weeks, months, or years. It is sometimes relieved by hemorrhage, sometimes passes off without either this, or the production of hemorrhoidal swellings, but most frequently either accompanies or produces tumours, and, if these have existed previously, provokes them into irritation or inflammation.

Hemorrhoidal tumours are not entirely identical in character. The following varieties may be distinguished. 1. The simplest form is that of varicose hemorrhoidal veins, consisting in a mere distension of the coats of the vessel, as in varicose veins of the leg. The same vessels are affected in the external and the internal piles, the veins above and below the sphincter being continuous, and not suffering dilatation in general at the sphincter, because compressed by that muscle. In their simplest state, these tumours are full of liquid blood, and may be readily evacuated by pressure, to be filled again immediately upon the removal of the pressure. After death they frequently disappear entirely, but may be rendered evident by injecting the inferior mesenteric vein. 2. The varicose tumours, in consequence of inflammation, or from rupture and resulting effusion of blood, undergo various changes. By inflammation their coats are thickened, coagulable lymph is effused into the neighbouring tissue, with which adhesions are contracted, the communication between the varix and the venous trunk is closed, and the blood within coagulates. By rupture, the blood escapes, and, being diffused in the cellular tissue, or forming a distinct cavity for itself either in the substance of the tissue, or between it and the mucous membrane, coagulates, and excites inflammation and consequent effusion of lymph in the contiguous parts. In either of these cases, a solid, vascular, hard, or more or less spongy tumour results, which, upon being opened, often discloses a clot of blood in its centre, thus showing its mode of production. 3. Instead of being varicose, the tumours sometimes consist of a sort of erectile tissue, which may be supposed to be formed by the opening of communications between contiguous venous and perhaps arterial radicals, and between both and the cellular tissue, which assumes a denser and firmer character, exhibiting numerous interlacing fibres. 4. Fleshy tumours may originate from the altered varices described above, by the organization of the coagulated blood in their centre, or its absorption and the deposition of organizable lymph. Or they may be produced, as Burne suggests, by a circumscribed thickening of the submucous cellular tissue, which, thus projecting somewhat into the cavity of the rectum, is carried down during defecation, and, being arrested by the contraction of the sphincter, becomes inflamed and enlarged, so as not to admit of return. 5. Tumours formed in any of the above modes may, by the influence of adhesive inflammation and subsequent absorption, be converted into dry, hard, indolent, wart-like projections in or near the anus; and, even though originating under the mucous membrane, may be covered with skin, in consequence of a not unfrequent transformation of that membrane, when prolapsed and exposed

long to the air. Another sequela of the proper hemorrhoids consists in folds of the mucous membrane or skin in or near the anus, resulting from the absorption of the contents of previous tumours.

Symptoms and Course of Hemorrhoids. The patient experiences a feeling of heat, fulness, and dull pain about the sacrum and anus, radiating more or less to surrounding parts. This continues for a few days, disappears, and again returns; and the event may occur several times without attracting much attention. At length the patient becomes conscious of a swelling, or a sensa tion as if a foreign body were in the anus or above it, and, applying his finger after an evacuation, discovers a small tumour of the size of a pea or larger, which either remains perceptible or retires, according as it originated without or within the sphincter. In other instances, the tumour appears to be formed suddenly in consequence of severe straining at stool. It is covered by the mucous membrane of the rectum, or, if external, partly by this and partly by the neighbouring skin, which is generally movable over it. The little tumour gradually increases; others form around it, occasionally clustering like a bunch of grapes; and a mass at length results, often as large as a pigeon's egg, and sometimes much larger. The progress, however, of the tumour is not uniform. During the periods of hemorrhoidal congestion, it increases most rapidly, acquiring an augmented volume at each successive period, though diminishing and sometimes almost disappearing in the intervals. In its ordinary uninflamed state, the tumour has little sensibility, but, when inflamed or strangulated by the sphincter, it becomes the seat of burning, stinging and otherwise very painful sensations, is often exquisitely tender to the touch, and renders defecation difficult, and sometimes exceedingly distressing. Shooting pains extend from it to the back, down the thighs, and to the viscera of the pelvis; irritation is sometimes radiated to the prostate gland, bladder, and uterus; and difficult micturition is not unfrequently produced. Sometimes the patient can neither stand, walk, nor sit with comfort, and finds the horizontal position the only one tolerable.

The phenomena of piles are somewhat different, according as they are external or internal. In the external piles, a tumour is observed on the verge of the anus, of greater or less extent, sometimes on one side only of the aperture, sometimes completely surrounding it, and in the latter case usually presenting an unequal outline, as if consisting of several tumours separated by shallow furrows. The consistence and colour of the tumour vary according to its character. If varicose, it is of a violet colour, soft, and more or less removable by pressure; if fleshy, it is of a red colour, solid, firm, and elastic. It has usually a broad base; and the fleshy tumour is often elongated from before backward, in consequence of being pressed on each side by the buttocks. When inflamed, these piles are peculiarly inconvenient by interfering with exercise in almost every way, and even with sitting. The internal piles are attended with a sense of distension which provokes a constant disposition to go to stool, and are peculiarly painful during the act of defecation. At first, though they are apt to descend at each evacuation, they usually return spontaneously when the straining ceases; but, after having acquired a certain magnitude, they can be restored to their position within the sphincter, after protrusion, only by the aid of the finger of the patient. When without the sphincter, they are rendered very painful by its contraction, but become comparatively easy when returned. After a time they descend when the patient walks or stands, espe cially if the rectum is full, and great inconvenience is experienced from the irritation and excoriation to which they are subjected. When thus extruded, they are sometimes strangulated by the sphincter, and become in consequenos so much inflamed and swollen, that the patient cannot himself restore them,

and even the surgeon finds considerable difficulty. Occasionally, in this condition, they burst, and by the discharge of blood are so much diminished in size, and relieved, as to admit of easy reduction. In other cases, they swell enormously, become gangrenous, and, after having occasioned vast suffering and inconvenience to the patient, slough off, and terminate finally in a radical cure. There are the same differences in colour and consistence in the internal as in the external piles. The fleshy tumours are sometimes narrow at the base, and bear no inconsiderable resemblance to polypi of the rectum.

Both the internal and external piles occasionally suppurate, forming abscesses or ulcers which are often very troublesome, ending sometimes in the establishment of fistula, though in other cases they eventuate more favourably, and even lead to a permanent cure.

More or less hemorrhage often attends defecation, the blood proceeding either from the abraded mucous coat, or from a rupture of the tumour, or from an oozing over its whole surface in an inflamed state. In general the bleeding is very slight, not more than sufficient to tinge the feces. But it is sometimes copious, and, in a few comparatively rare cases, very much so, producing by its frequent returns, and the quantity discharged at each time, an alarming and dangerous anemic condition of the patient. Some individuals are liable to periodical attacks of this hemorrhage, corresponding probably with the periodical returns of the hemorrhoidal congestion; and it is not always easy to decide, whether the bleeding is or is not connected with the tumours. The blood sometimes collects in large quantities in the rectum before being discharged. It is in some instances venous, in others arterial; being of the former character probably when proceeding from a ruptured tumour, and of the latter when from other sources.

During the discharge of the feces, fissures are sometimes produced in the mucous coat around the anus, which afterwards bleed at each evacuation, and become occasionally so tender as to render the act of defecation almost insupportable.

In consequence of chronic inflammation of the hemorrhoidal tumours, and of the neighbouring mucous membrane, a discharge of whitish mucus sometimes occurs, which was formerly distinguished by the name of white piles, or anal leucorrhœa.

Among the local consequences of piles is sometimes a thickening of the lower part of the rectum, resulting from repeated inflammation, which forms a sort of stricture, and very much interferes with the discharge of the feces. The general health often suffers much from long-continued and aggravated piles. Preventing exercise, and rendering necessary an almost constant use of medicines which interfere more or less with digestion, they lead to the production of dyspepsia with its train of evils, and, besides, call various organs into a direct sympathy, which cannot but impair their functions. Paleness, emaciation, and mental irritability or dejection, or at least a very uncertain condition of the feelings, are among their frequent concomitants; and dropsy sometimes results from the anemic state of the blood.

Diagnosis.-The complaints with which piles are most likely to be confounded, are polypus of the rectum, and prolapsus ani. It is, however, only the solid and firm hemorrhoidal tumours that resemble polypus. They may be distinguished by the firmer consistence of polypus, and by its gradual and steady developement, without the periodical congestions, and alternate increase and diminution which characterize piles. The latter, moreover, generally have a broad base, while the polypus is joined to the mucous membrane by a sort of peduncle; but this is not a certain criterion; as the two conditions are sometimes reversed. Piles are usually distinguishable from pro